Are scotomas from retinal holes permanent?

Scotomas from Retinal Holes: Permanence and Management

Scotomas from retinal holes may be permanent, but many can improve or resolve over time depending on the location, treatment approach, and whether anatomical closure is achieved. 1

Understanding Retinal Holes and Associated Scotomas

Retinal holes can cause scotomas (blind spots in vision) through several mechanisms:

• Direct tissue loss at the hole site
• Surrounding retinal detachment or fluid accumulation
• Secondary effects from treatment interventions

Types of Retinal Holes and Their Visual Impact

• Full-thickness macular holes (FTMH):

  • Cause central scotomas that significantly impact visual acuity
  • Without treatment, only 5% will maintain visual acuity of 20/50 or better
  • Approximately 40% will deteriorate to 20/200 or worse 2
  • Only 3-11% of cases close spontaneously 2

• Peripheral retinal holes:

  • May cause peripheral scotomas that are less noticeable
  • Can progress to retinal detachment if untreated

Permanence of Scotomas: Key Determining Factors

1. Location of the Hole

• Macular holes: Scotomas in central vision are more noticeable and impactful
• Peripheral holes: Scotomas may be asymptomatic or minimally symptomatic

2. Treatment Outcomes

• Successful treatment with hole closure:

  • Scotomas detected in and around macular holes before surgery gradually reduce or disappear in most cases 3
  • Studies show that 77.4% of scotomas detected around macular holes decreased gradually after successful treatment 3

• Untreated or unsuccessfully treated holes:

  • Scotomas typically remain permanent
  • Visual acuity continues to deteriorate in 60% of untreated full-thickness macular holes 2

3. Treatment Complications

• Post-surgical scotomas:
  • Peripheral visual field loss occurs in approximately 70% of patients after vitrectomy with gas tamponade for macular holes 4
  • These iatrogenic scotomas may be permanent and are most commonly found in the temporal and lower periphery 4
  • Paracentral scotomas have been reported after vitrectomy for retinal detachment repair 5

Management Approach

1. Diagnosis and Assessment

• Comprehensive dilated fundus examination with scleral depression to identify:

  • Location and size of retinal holes
  • Presence of vitreous traction
  • Signs of shallow retinal detachment 1

• Optical Coherence Tomography (OCT) to:

  • Confirm presence and extent of retinal holes
  • Evaluate macular architecture
  • Monitor treatment response 1

• Visual field testing to map the scotoma and correlate with the anatomical defect 1

2. Treatment Options

• For symptomatic retinal holes without detachment:

  • Laser photocoagulation or cryotherapy to create chorioretinal adhesion around the break 1
  • Success rates for preventing progression to detachment exceed 95% 1

• For macular holes:

  • Vitrectomy with internal limiting membrane peeling has approximately 90% success rate for holes <400 μm 1
  • Visual improvement occurs in approximately 58% of cases 4
  • Anatomic success after one surgical procedure is achieved in about 85% of cases 4

3. Follow-up and Monitoring

• First follow-up 1-2 weeks post-treatment to assess chorioretinal scar formation
• Second follow-up 2-6 weeks post-treatment to evaluate effectiveness
• Long-term follow-up every 3-6 months due to 10-16% risk of developing additional breaks 1

Special Considerations and Caveats

• Spontaneous resolution: Some scotomas may resolve spontaneously if the retinal hole closes without intervention (occurs in 3-11% of macular holes) 2

• Treatment-related scotomas: Be aware that treatment itself can cause new scotomas:

  • Laser photocoagulation creates intentional retinal scars that cause small scotomas
  • Vitrectomy with gas tamponade can cause peripheral visual field defects in up to 70% of cases 4

• Patient education: Patients should be informed that:

  • Some scotomas may persist despite successful anatomical closure
  • New symptoms warrant immediate re-evaluation
  • Regular follow-up is essential even after successful treatment 1

• Risk-benefit assessment: For some peripheral retinal holes without progression, observation may be appropriate as treatment carries its own risks 6